Laserfiche WebLink
`'I •SFILE C COP Y <br /> an Joaquin County • <br /> z Environmental Health De artment <br /> P ,lll, ,-°,I� �� SITE <br /> 600 East Main Street, Stockton, CA 95202-36 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.orp�hd 2006 UNIT IV <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 7 YEAR FROM DATE ,4��i <br /> ISSdED.�,,,-\,�-r•1-1�) FC <br /> _1 ..t <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> G-7 /� ('� Assessors <br /> WELL Location / /S(p �/�/'/ C C/�Cross Street d P- City�7h'C�1�.✓ Zip Parcel#-/OZ270-/D <br /> PROPERTY" ' / <br /> Owner] /L b Off Address j0 Z y(�/,706i t/,L i11I/JLit >5� n/ Zi ZO ' <br /> YS ( p 6 _Phone#L_ _ <br /> C•57 Contractor V/Q. AleYY— Address 52'?7—///� X9FC0/ City pA La,-1 Zip 9yr.33 Lic#7#5`/Z7 Phone#yc7S-5aL 7 � <br /> Consultant/Sub Cntr LF,�1n/C Address 7j�'JD.[�eUVHS l3LtOO Citt Lic# Phonegg!6-- 8G 0 32�O <br /> GIS Coordinates:X.3S,0 O Z 3°/y ,y/Z/.3/7g°InJ ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> pf EW WE L/BORING (CPT, EOPROB HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> /}SOIL BORING# D Ao f r f 5'•(-p$'� 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0.Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE_ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 3/9" <br /> I <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS f , TYPJPF CASING: Q'STEEL 0 PVC �THER:jp�DA) <br /> AEAL rPOR 0 MUD ROTARY DEPTH OF GROUT S � TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> p AIR SPARGE/OZONE &PV-SH POINT(o or CPT)GROUT SEAL PUMPED: Yes J No 4NOT ' MAXIMyM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS�•QrJ 78N r re �U�LR-y <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH I r-I 5r p BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> D CONDUCTOR CASING PROPOSED A ,A (if YES,lila specifications i7-comment section) <br /> COMMENTS:/D Nob W. S 14A V e�E 5 ro 01 PA-)< (XP F�1�7LC 4, 1111 1✓�S >-CJ L AC <br /> 0crt* of 5 p�odEs Cor*-p t) AS p A wt'v'r S7+rrp 1rro� 13orn cs E-W d_ot6er'ls) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordi T. <br /> nce�s, Rules and Regulations,and all applicable California State Laws. <br /> Signed 66(` — Title/Company mfPle-L / <br /> VC <br /> PdntNjmLTF <br /> f'A'-"_IkkM Date <br /> DEPARTM IT USE ONLY q <br /> SITE MAP IN UNIT IV FILE,ADD": <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued. 'tom O V Area <br /> Grout Inspection By Date Final Inspection By. if <br /> Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 296 y N os 2 SR# 6 <br /> C-57_ WC_-WAIVER ✓ C-57 Letter of Authorization to Sigpn per Encroachment doc <br /> EHD29-02-001 WEB < ff' Z R O <br /> 7{ / <br /> 9/1112007 ALiV <br />